Timely and specialized care key to treating people with spinal cord injury

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31 May 2018

RHI and its research partners author a special focus issue on traumatic spinal cord injury based on research that examines the patient's journey through the health care system

When someone sustains a spinal cord injury (SCI), does it matter where they get injured? What level of care can they expect to receive? Does specialized rehabilitation make a difference in recovery time? These are just some of the questions answered in a series of peer-reviewed papers in a Focus Issue authored by researchers at the Rick Hansen Institute and its Canadian SCI network. While questions related to specialized services and timely care have been extensively explored in conditions such as stroke and cardiac care, there is mounting evidence that they are also important factors in determining outcomes for individuals who have sustained a SCI.

Opportunities to optimize patient care

"The ACT project enabled us to view and evaluate SCI care at a 'systems level' by examining both upstream and downstream effects."

- Dr. Vanessa Noonan

"The ACT project enabled us to view and evaluate SCI care at a 'systems level' by examining both upstream and downstream effects," says Dr. Vanessa Noonan, the Institute's Director of Research & Best Practice Implementation. "It will also allow us to explore how we can streamline care and ensure appropriate access to specialized services in a timely manner."The Focus Issue is based on the Institute's Access to Care and Timing (ACT) project which describes a patient's journey through the health system in Canada following a traumatic SCI. From a health system perspective, SCI is typically described by phase of care (e.g. first response, acute hospital, rehabilitation, community). There are numerous patient journeys an individual can take once he or she enters the health care system. For example, some individuals who sustain an injury may be taken to a local hospital before being transferred to a hospital specializing in SCI care while others might go directly depending on the location of their injury. Some individuals may receive specialized rehabilitation while others do not. As a result, individuals with SCI frequently report being overwhelmed by how complex the system is and health care providers frequently report that the system is not consistent at producing optimal outcomes for all patients – for some patients the health care system works extremely well, but for others, it can be challenging.

The Focus Issue describes opportunities within each part of the patient journey that can impact an individual's outcome. Among the findings, the authors reported that individuals who sustained an injury close to a specialized hospital were more likely to receive specialized care sooner, which has been shown to improve outcomes. Individuals who were older or injured slightly further away didn't receive specialized care until an average of seven hours later.

When it came to rehabilitation, individuals who received specialized rehabilitation as part of inpatient treatment were six times more likely to return home. Those who did not receive specialized rehabilitation were more likely to live in a nursing home or places other than home after their injury.

"This variation in care provides a great opportunity for an organization like the Institute to study what constitutes optimal care so all Canadians can receive the best care."

- Dr. Christiana Cheng

The biggest surprise to come out of the Focus Issue, according to Dr. Christiana Cheng, Research Associate at the Institute, was the differences in care, such as lack of standardized discharge processes and rehabilitation admission criteria found at SCI-specialized hospitals in Canada. "This variation in care provides a great opportunity for an organization like the Institute to study what constitutes optimal care so all Canadians can receive the best care."

Other areas covered in the Focus Issue include benefits of increased rehabilitation intensity, challenges of living in rural versus urban settings, the financial costs of hospital-acquired secondary complications and how to mitigate them and the future financial needs of SCI care.

As many authors involved in the publications have the dual role of researcher and clinician, the Focus Issue also helped inform their own clinical practice.

"Early intervention for acute SCI using systems-based approaches is critical to optimize outcomes for people with SCI."

- Dr. Michael Fehlings

"Early intervention for acute SCI using systems-based approaches is critical to optimize outcomes for people with SCI," said Dr. Michael Fehlings, a Toronto-based neurosurgeon. "Integration of all facets of care, including early emergency extrication from the injury scene, through acute care, rehabilitation and community integration is critical for optimizing clinical outcomes and reducing secondary complications. Teamwork is key!"

Influencing policy and practice

The authors agreed that research has come a long way in improving SCI care, but knowledge gaps still exist. Decisions regarding health care provision and their systematic and financial implications are extremely complex, but embarking on a project that is helping to identify and close those gaps, is the first step in improving outcomes for people with SCI. Ultimately, the goal of these findings is to help support health care decisions makers implement evidence-based policy decisions.

The ACT Focus Issue, entitled "Optimizing Clinical Decision Making in Acute Traumatic Spinal Cord Injury" is published in the Journal of Neurotrauma. You can view a summary of the articles here.